
<?php if(!empty($message)) {
  echo $message;
}?>
 <div class="row-fluid">
 
     <div class="span4">
        <h4 align="center"class="heading">CUSTOMER INFORMATION</h4>
		<label>Service No.</label>
		<input type="text" class="span4"value=""name="service_id" id="service_id" readonly/>
		<label>Choose Date</label>
		
        <input data-date-format="yyyy/mm/dd" type="text" class="span7 datepicker " id="datepicker" name ="datepicker" />
          
       </div>
	
	  <div class="span4">
        <h4 align="center" class="heading">INFORMATION FOR ENGINEER</h4>
        <label>Model No.</label>
		<input type="text"  name="model_no" id="modelNo" required/>
		<span class="text-error"><?= form_error('model_no'); ?></span>
		<label>Product No.</label>
		<input type="text"  name="product_no" id="productNo" required/>
		<span class="text-error"><?= form_error('product_no'); ?></span>
		 <label>Serial No.</label>
		<input type="text"  name="serial_no" id="serialNo" required/>
		<span class="text-error"><?= form_error('serial_no'); ?></span>
		 <label>Password</label>
		<input type="text" name="password" id="password"required/>
		<span class="text-error"><?= form_error('password'); ?></span>
		 <label>Operating System</label>
		<input type="text"  name="operating_system" id="operatingSystem" required/>
		<span class="text-error"><?= form_error('operating_system'); ?></span>
		 <label>Country Of Purchase</label>
		 <select name="country_purchase" id="countryPurchase">
			 <?php foreach($country as $row){ 
             echo "<option value=$row->name>$row->name; </option>";}?>
           </select> 
		   <span class="text-error"><?= form_error('country_purchase'); ?></span>
	  <label> Issue Reported</label>
	  <textarea rows="6" name="issue_reported" id="issueReported"></textarea>
	  <span class="text-error"><?= form_error('issue_reported'); ?></span>
	  <label> Demo Engineer Diagnosis</label>
	  	<textarea rows="6" name="demo_diagnosis" id="diagnosis"></textarea>
		<span class="text-error"><?= form_error('demo_diagnosis'); ?></span>
      </div>
	  <div class="span4">
			<h4 align="center" class="heading">CUSTOMER ACCESSORIES</h4>
			<div class="span5">
			  <label class="checkbox">
			  <input type="checkbox" value="1"name="chk_adapter" id="chkadapter"/> AC Adapter</label>
			</div>
			  <div class="span6">
			  <input type="text" placeholder="Enter AC Adapter Details" id="adapter" name="adapter"/>
			</div>
			<div class="span5">
			<label class="checkbox">
			<input type="checkbox" value="1"name="chk_driver" id="chkdriver"/> Driver CD</label>
			</div>
			 <div class="span6">
			 <input type="text" placeholder="Enter DRIVER CD Details" id="drivercd" name="drivercd"/>
			</div>
			<div class="span5">
			<label class="checkbox"><input type="checkbox" value="1"name="chk_bag" id="chkbag"/> Bag</label>
			</div>
			<div class="span6">
			 <input type="text" placeholder="Enter Bag Details" id="bag" name="bag"/>
			</div>
			<div class="span5">
			<label class="checkbox">
			<input type="checkbox" value="1"name="chk_hdd" id="chkhdd"/> HDD</label>
			</div>
			 <div class="span6">
			 <input type="text" placeholder="Enter HDD Details" id="hdd" name="hdd"/>
			 </div>
			 <div class="span5">
			 <label class="checkbox">
			 <input type="checkbox" value="1"name="chk_powercord" id="chkpowercord"/> Power Cord</label>
			 </div>
			 <div class="span6">
			 <input type="text" placeholder="Enter Power Cord Details" id="power_cord" name="powerCord"/>
			 </div>
			 <div class="span5">
			 <label class="checkbox">
			 <input type="checkbox" value="1"name="chk_carry" id="chkcarry"/>Carry Case Belt</label>
			 </div>
			 <div class="span6">
			 <input type="text" placeholder="Enter Carry Case Bag Details" id="carry_case" name="carryCase"/>
			 </div>
			 <div class="span5">
			 <label class="checkbox">
			 <input type="checkbox" value="1"name="chk_optical" id="chkoptical"/>Optical Drive</label>
			 </div>
			 <div class="span6">
			 <input type="text" placeholder="Enter Optical Drive Details" id="optical_drive" name="opticalDrive"/>
			 </div>
			 <div class="span5">
			 <label class="checkbox">
			 <input type="checkbox" value="1" name="chk_fax" id="chkfax"/>Fax Modem Card</label>
			 </div>
			 <div class="span6">
			 <input type="text" placeholder="Enter Fax Modem Details" id="fax_modem" name="faxModem"/>
			 </div>
			 <div class="span5">
			 <label class="checkbox">
			 <input type="checkbox" value="1"name="chk_network" id="chknetwork"/>Network Card</label>
			 </div>
			 <div class="span6">
			 <input type="text" placeholder="Enter Network Details" id="network_card" name="networkCard"/>
			 </div>
			 <div class="span5">
			 <label class="checkbox">
			 <input type="checkbox" value="1"name="chk_memory" id="chkmemory"/>Memory</label>
			 </div>
			 <div class="span6">
			 <input type="text" placeholder="Enter Memory Details" id="memory" name="memory"/>
			 </div>
			 <div class="span5">
			 <label class="checkbox"><input type="checkbox" value="1"name="chk_capacity" id="chkcapacity"/>Capacity</label>
			 </div>
			 <div class="span6">
			 <input type="text" placeholder="Enter Capacity Details" id="capacity" name="capacity"/>
			 </div>
			 <div class="span5">
			 <label class="checkbox">
			 <input type="checkbox" value="1"name="chk_tray" id="chktray"/>Tray</label>
			 </div>
			 <div class="span6">
			 <input type="text" placeholder="Enter Tray Details" id="tray" name="tray"/>
			 </div>
			 <div class="span5">
			 <label class="checkbox">
			 <input type="checkbox" value="1"name="chk_battery" id="chkbattery"/>Battery</label>
			 </div>
			 <div class="span6">
			 <input type="text" placeholder="Enter Battery SL. NO." id="battery" name="battery"/>
			 </div>
			 <div class="span5">
			 <label class="checkbox">
			 <input type="checkbox" value="1"name="chk_cradle" id="chkcradle"/>Cradle</label>
			 </div>
			 <div class="span6">
			 <input type="text" placeholder="Enter Cradle Details" id="cradle" name="cradle"/>
			 </div>
			 <div class="span5">
			 <label class="checkbox">
			 <input type="checkbox" value="1"name="chk_fdd" id="chkfdd"/>FDD</label>
			 </div>
			 <div class="span6">
			 <input type="text" placeholder="Enter FDD Details" id="fdd" name="fdd"/>
			 </div>
			 <div class="span5">
			 <label class="checkbox">
			 <input type="checkbox" value="1"name="chk_itb" id="chkitb"/>ITB</label>
			 </div>
			 <div class="span6">
			 <input type="text" placeholder="Enter ITB Details" id="itb" name="itb"/>
			 </div>
			 <div class="span5">
			 <label class="checkbox">
			 <input type="checkbox" value="1"name="chk_wireless" id="chkwireless"/>Wireless LAN</label>
			 </div>
			 <div class="span6">
			 <input type="text" placeholder="Enter Wireless LAN Details" id="wireless" name="wireless"/>
			 </div>
		 </div>	</div>
		 <div class="row-fluid">
		 <h4 align="center"class="heading"> MISCELLANEOUS COMMENTS:</h4>
		 <div class="span4"><label> Scratches</label><textarea rows="7" name="scratches"> </textarea>     </div> <div class="span4"> <label> Damages</label><textarea rows="7" name="damage"> </textarea> </div> <div class="span3"> <label> Others</label><textarea rows="7" name="other"> </textarea> </div>
		 
         <div class="span5"></div><div class="span3"><input type="submit" class="btn btn-success " value="Save" id="caseSubmit"/></form>	</div><div class="span3"> </div>	</div>

